SELECTIVE AXILLARY DISSECTION

IN

CARCINOMA BR EAST

Dr.Anil Haripriya

Assistant Professor

General Surgery

Tumour size and axillary lymph node status are the most important

prognostic factors in potentially curable carcinoma of the breast. 

Physical examination, radiologic imaging of the axilla or prognostic

models based on primary tumour characteristics cannot accurately

predict the occurrence of axillary metastases1-2. Hence axillary lymph

node dissection is an important staging procedure in the surgical

treatment of breast cancer. 

National Institute of Health Consensus recommended a level I and II

axillary lymph node dissection for staging and regional control of breast

cancer 3 . To minimize the short and long term morbidity associated with

axillary lymph node dissection, some investigators have proposed a

limited axillary dissection 4 . This procedure has less morbidity but

misses 24% to 42% of axillary metastases (5-6). 

Selective axillary dissection means that one should be able to select the

patients with breast cancer for total axillary dissection from the ones that

don’t need total axillary clearance. This means that if the axilla is

involved, it should be completely cleared of all nodal tissues as both the

number and level of involved nodes have important prognostic value.

Similarly if the axillary nodes are not involved they should be left

untouched to avoid the morbidity of total axillary dissection. 

There is general agreement that total lymphadenectomy is indicated in

patients with clinical suspicious nodes or pathologically proved

metastases to the regional lymph nodes. A major controversy exists

regarding the utility of this procedure for patients with clinical stage I

(CS-I) disease because most of these patients are without nodal

metastases and therefore can derive no benefit from regional lymph

adenectomy. 

% of cases where axillary nodes were involved. 

T1 Tumours 11.3% positive cases 

T2 Tumours 28.3% 

T3 Tumours 42.8% 

Since breast cancer is being detected at early stage due to screening

procedures the chances of axillary nodes being free of cancer are high

and hence the need for selection of axillary dissection.  

Selection is possible if we can prove that a single axillary node (Sentinel

node) initially receives malignant cells from a breast carcinoma and that

an uninvolved sentinel node reliably forecasts a disease free axilla. 

This concept of sentinel node biopsy in carcinoma breast is not new.

Oliver cope referred to the Delphian node in 1963 as the lymph node

that will “fortell the nature of a disease process” affecting a nearby

organ. 

 That the predicting value of the first level node is considerable was

shown by Veronesi etall7 in a study of 539 patients with carcinoma of the

breast treated with total axillary dissection and with positive axillary

nodes. Only in 1.5% of the cases the first level was skipped by

metastases and in 0.4% of cases both first and second levels were

missed.    

They also showed that axillary lymph node metastases occur in an

orderly fashion and that predictive value of first level is considerable i.e.

when first level nodes are clear chances of 2nd and 3rd level involvement

is rare. When first level lymph nodes are involved, chances of

metastases being present at higher levels is high. Of the first level nodes

– if one can detect the first or the lymph node nearest the site of primary

carcinoma (called sentinel lymph node) its pathological status can be

reliably used to selectively dissect or not to dissect the whole axilla. 

The validity of this concept was first demonstrated for melanoma over 10

years ago by Morton & colleagues8. Patent blue V dye was injected

close to the primary lesion and the blue stained sentinel node was later

found by dissection. Various dyes have been tested to optimise the

kinetics both in terms of take up and transport and retention by the first

node to receive that lymph. Blue dyes have been used to identify the

sentinel node in breast cancer, either alone or in conjunction with other

radioactive materials. 

In 1996, John J. Albertini et al9 carried out a study to identify the sentinel

lymph node by intra operative lymphatic mapping using a combination of

a vital blue dye and filtered technitium – labelled sulfur colloid. The

sentinel lymph node was identified and removed followed by a definitive

cancer operation and complete axillary dissection.                 

Their results indicated that SLN was successfully identified in 92% of

patients using the two lymphatic mapping procedures. 32% were found

to have metastatic disease and SLN was tested positive in all 32% of

patients. 

Turner etall10  from Joyce Eisenberg Keefer Breast Centre, at Santa

Monica, California used 3 to 5 ml. of 1% isosulfan blue vital dye into the

breast parenchyma surrounding the primary tumor. Sentinel node was

recognised in the axillae, removed and then level I & II were also

dissected. Sentinel nodes were examined by H&E and I.H.C. (Immuno

histochemistry). Where sentinel nodes were free by H&E and I.C.H. all

nonsentinel nodes were examined by I.H.C. only one sentinel node

negative patient was positive by I.H.C. from non sentinel nodal mass. In

addition 14.3% of sentinel nodes that were negative by H&E stain were

tested positive with I.H.C. 

Umberto Veronesi etall11  from European Institute of Oncology in 163

women with operable breast cancer injected microcolloidal particles of

human serum albumin labelled with technitium– 99m. This tracer was

injected subdermally close to the tumor site on the day before surgery

and scintigraphic images of breast and axille were taken at 10,30 mins.

and 3 hrs. later.  A mark was placed over the site where radioactive

node existed. A small  Ɣ- ray detector probe was used at surgery to

locate the sentinel node and made possible its removal through a small

separate axillary incision. Complete axillary dissection was then carried

out. The results show that they could accurately predict axillary lymph

node status in 97.5% of the patients in whom sentinel node was

identified. In 38% of the cases with metastatic axillary nodes, the

sentinel node, was the only positive node 

Hence from the ongoing studies 

·          It is possible to dissect sentinel nodes with the help of vital blue

dyes and or lympho scintigraphy. There are advantages and

disadvantages of vital dyes and lympohscintigraphy. Vital blue dye can

be injected few minutes before surgery while lympohscintigraphy must

be carried out at least 2 hours before surgery.  

        Disadvantage of dye method is that axillary tissue must be

dissected blindly until the blue node is located and this can be few cms.

away  from the skin incision. The advantage of hand held probe is that it

locates the node and indicates exactly where the skin incision should be

made and guides the dissection, which is quite successful.  

·Sentinel node is a reliable good predictor of the axillary nodal status. 

·Frozen section facilities and multiple sectioning of sentinel node is a

must, if second operation is to be avoided. 

· Immunohistochemistry and PCR enhances the detection of

micrometastatis. Micrometastatis is also a prognostic factor as of today. 

· Extensive microcalcification or multifocality is a contraindication to the

injection method because in such cases sentinel nodes may be falsely

negative. 

· Another advantage of sentinel node dissection is its use in Neo

adjuvant therapy in Carcinoma breast. 

·It provides the pathologists only 1-2 nodes to perform a more detailed

and focussed examination and possibly PCR analysis, serial sectioning

for immunohistochemical staining. 

There is a word of caution. Before sentinel node biopsy is adopted

routinely in breast cancer management, the outcome of several clinical

trials that are presently comparing survival in patients staged by this new

approach with that of patients receiving traditional axillary management

should be awaited. There is also a learning curve in dissecting sentinel

node and hence for the first few cases both sentinel lymph nodes and

complete axillary clearance be carried out in individual hands and

reliability tested. 

References 

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2.        Rosen PP, Groshen S, Saigo PE, et al. A long-term follow-up study of survival in

stage I (T1N0M0) and Stage II (T1N1M0) breast carcinoma. J.Clin Oncol 1989; 7:355-366.  

3.        NIH Consensus Development Conference. Treatment of early stage breast cancer. J.

Natl Cancer Inst. 1992;   11:1-5

4.        Steele RJC, Forrest APM, Gibson T, et al. The efficacy of lower axillary sampling in

obtaining lymph node status in breast cancer a controlled randomized trail. Br. J.Surg

1985; 72:368-369.

5.        Kissin MW, Thompson EM, Price AB, et al. The inadequacy of axillary sampling in

breast cancer, Lancet 1982; 1:1210-1212.

6.        Moffat FL, Senofsky GM, Davis K. et al. Axillary node dissection for early breast

cancer; some is good, but all is better. J.Surg Oncol 1992; 51:8-13.

7.        Veronesi U, Rilke F, Luini A, Sacchini V, Galimberti V, Campa T et al. Distribution of

axillary node  metastases by level of invasion. An analysis of 539 cases. Cancer 1987;

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8.        Morton DL, Wen DR, Wong JH, Economou JS, Cagle LA, Storm FK et al. Technical

details of intraoperative lymphatic mapping for early stage melanoma. Arch Surg 1992;

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9.        Albertini JJ, Lyman GH, Cox C, Yeatman T, Balducci L, Ku N et al. Lymphatic

mapping  and sentinel node biopsy in the patient with breast cancer. JAMA 1996;276:1818-

22.

10.     Turner RR, Ollila DW, Krasne DL, Giuliano AE. Histopathologic validation of the

sentinel lymph node hypothesis for breast carcinoma Ann Surg 1997;226:271-8.

11.      Veronesi U, Paganelli G, Galimberti V, Viale G, Zurrida S, Bedoni M et al. Sentinel-

node  biopsy to avoid axillary dissection in breast cancer with clinically negative lymph-

nodes. Lancet 1997; 349:1864-7.